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Department of Veterans Affairs Office of Inspector General

Office of Healthcare Inspections

Report No. 15-05162-93

Review of Community Based Outpatient Clinics and Other

Outpatient Clinics of

Central California VA Health Care System

Fresno, California

February 11, 2016

Washington, DC 20420

To Report Suspected Wrongdoing in VA Programs and Operations Telephone: 1-800-488-8244

E-Mail: [email protected] (Hotline Information: www.va.gov/oig/hotline)

mailto:[email protected]

http://www.va.gov/oig/hotline

Review of CBOCs and OOCs of Central California VA Health Care System, Fresno, CA

Glossary

BBP bloodborne pathogen

CBOC community based outpatient clinic

EHR electronic health record

EOC environment of care

FY fiscal year

HT home telehealth

lab laboratory

NA not applicable

NM not met

OIG Office of Inspector General

OOC other outpatient clinic

PC primary care

PTSD post-traumatic stress disorder

VAMC VA Medical Center

VHA Veterans Health Administration

VA OIG Office of Healthcare Inspections


Table of Contents Page

Executive Summary ................................................................................................... i

Objectives, Scope, and Methodology....................................................................... 1 Objectives ............................................................................................................... 1 Scope...................................................................................................................... 1 Methodology ........................................................................................................... 2

Results and Recommendations ................................................................................ 3 EOC ........................................................................................................................ 3 HT Enrollment ......................................................................................................... 8 Outpatient Lab Results Management ...................................................................... 9 PTSD Care ............................................................................................................. 10

Appendixes A. Clinic Profiles ..................................................................................................... 11 B. Patient Aligned Care Team Compass Metrics ................................................... 12 C. Veterans Integrated Service Network Director Comments ................................ 16 D. Facility Director Comments ............................................................................... 17 E. Office of Inspector General Contact and Staff Acknowledgments ..................... 19 F. Report Distribution ............................................................................................. 20 G. Endnotes ........................................................................................................... 21

VA OIG Office of Healthcare Inspections


Executive Summary

Review Purpose: The purpose of the review was to evaluate selected patient care activities to determine whether the Community Based Outpatient Clinics and other outpatient clinics under the oversight of the Central California VA Health Care System and Veterans Integrated Service Network 21 provide safe, consistent, and high-quality health care. The review evaluated the clinics’ compliance with selected requirements for home telehealth enrollment, outpatient lab results management, and post-traumatic stress disorder care. We also randomly selected the Merced VA Clinic, Merced, CA, as a representative site and evaluated the environment of care on December 1, 2015.

Review Results: We conducted four focused reviews and had no findings for the Environment of Care, Home Telehealth Enrollment, and Post Traumatic Stress Disorder Care reviews. However, we made one recommendation for improvement in the following review area:

Outpatient Lab Results Management: Ensure that clinicians consistently notify patients of laboratory results within 14 days as required by VHA.

Comments

The Veterans Integrated Service Network and Facility Directors agreed with the Community Based Outpatient Clinic and other outpatient clinic review finding and recommendation and provided an acceptable improvement plan. (See Appendixes C and D, pages 16-18, for the full text of the Directors’ comments.) We will follow up on the planned actions until they are completed.

JOHN D. DAIGH, JR., M.D. Assistant Inspector General for

Healthcare Inspections

VA OIG Office of Healthcare Inspections i


Objectives, Scope, and Methodology

Objectives

The CBOC and OOC reviews are an element of the OIG’s efforts to ensure that our Nation’s veterans receive high-quality VA health care services. As such, the CBOC and OOC reviews are recurring evaluations of selected outpatient care activities that focus on patient care quality and the EOC. In general, our objectives are to determine whether:

The selected CBOC is compliant with EOC requirements.

The CBOCs/OOCs are compliant with selected VHA documentation requirements for the enrollment, assessment, and monitoring of HT patients.

The CBOCs/OOCs are compliant with VHA requirements for the patient notification and follow up of selected outpatient lab results.

The CBOCs/OOCs are compliant with selected VHA requirements related to PTSD screening, diagnostic evaluation, and treatment.

Scope

To evaluate for compliance with requirements related to patient care quality and the EOC, we conducted an onsite inspection, reviewed clinical and administrative records, and discussed processes and validated findings with managers and employees. The review covered the following four activities:

EOC

HT Enrollment

Outpatient Lab Results Management

PTSD Care

The scope of this review is limited to the established objectives. Issues and concerns that come to our attention but are outside the scope of this standardized inspection will be reviewed and referred accordingly.

VA OIG Office of Healthcare Inspections 1


Methodology

The onsite EOC inspection was conducted at a randomly selected outpatient site of care that had not been previously inspected.1 Details of the targeted study populations for the HT Enrollment, Outpatient Lab Results Management, and PTSD Care focused reviews are noted in Table 1.

Table 1. CBOC/OOC Focused Reviews and Study Populations

Review Topic Study Population HT Enrollment All CBOC and OOC patients screened within the study period

of July 1, 2014, through June 30, 2015, who have had at least one “683” Monthly Monitoring Note and did not have Monthly Monitoring Notes documented before July 1, 2014.

Outpatient Lab Results

Management

All patients who had outpatient (excluding emergency department, urgent care, or same day surgery orders) potassium and sodium serum lab test results during January 1 through December 31, 2014.

PTSD Care All patients who had a positive PTSD screen at the parent facility’s outpatient clinics during July 1, 2014, through June 30, 2015.

In this report, we made one recommendation for improvement. The recommendation pertains to an issue that is significant enough to be monitored by the OIG until corrective actions are implemented.

The review was performed in accordance with OIG standard operating procedures for CBOC and OOC reviews.

1 Each outpatient site selected for physical inspection was randomized from all PC CBOCs, multi-specialty CBOCs, and heath care centers reporting to the parent facility and was operational and classified as such in VA’s Site Tracking Database by August 15, 2015.



Results and Recommendations

EOC

The purpose of this review was to assess whether CBOC managers have established and maintained a safe and clean EOC as required.a

We reviewed relevant documents and conducted a physical inspection of the Merced VA Clinic. The table below shows the areas reviewed for this topic. Any items that did not apply to this facility are marked NA. The facility generally met requirements. We made no recommendations.

Table 2. EOC

NM Areas Reviewed Findings Recommendations Document and Training Review

Managers monitored hand hygiene compliance. Managers had an Exposure Control Plan for BBP. Managers reviewed the Exposure Control Plan annually. Managers included an exposure determination for all job classifications in the Exposure Control Plan for BBPs. Managers included the Hepatitis B vaccine in the Exposure Control Plan for BBP. In the Exposure Control Plan for BBPs, managers provide the Hepatitis B vaccine to employees upon exposure to a BBP. In the Exposure Control Plan for BBPs, managers provide the Hepatitis B vaccine to employees within 10 days of job assignment. In the Exposure Control Plan for BBPs, managers document employees’ declination statements for the Hepatitis B vaccine.



NM Areas Reviewed (continued) Findings Recommendations In the Exposure Control Plan for BBPs, managers provide post exposure prophylaxis within 72 hours. Managers documented their consideration and implementation of safety needle devices. Managers documented their consideration and implementation of safety needle devices annually. Training for CBOC employees on the Exposure Control Plan for BBP has been provided within the past 12 months for those newly hired and annually for others. Managers have a policy/procedure for CBOC life safety elements. Managers have a policy for the management of clinical emergencies. CBOC managers have a policy for the management of mental health emergencies. Managers have a documented Hazard Vulnerability Assessment to identify potential CBOC emergencies. Managers reviewed the Hazard Vulnerability Assessment annually. Managers have a policy that requires CBOC staff to receive regular information on their responsibilities in emergency response operations. CBOC staff participate in regular emergency management training and exercises. Managers conducted fire drills at the CBOC at least once every 12 months for the past 24 months and documented critiques of the fire drills.



NM Areas Reviewed (continued) Findings Recommendations Managers have a policy/procedure for the identification of individuals entering the CBOC. Managers had a Workplace Behavioral Risk Assessment in place. Managers tested the alarm system or panic buttons in high-risk areas during the past 12 months. Managers had written procedures to follow in the event of a security incident. CBOC employees received training on the new chemical label elements and safety data sheet format. Managers have a policy/procedure for the cleaning and disinfection of telehealth equipment.

Physical Inspection The CBOC is clean. The furnishings and equipment are safe and in good repair. Hand hygiene facilities and product dispensers are working and readily accessible to employees. Personal protective equipment is available. Sharps containers are closable, easily accessible, and not overfilled. Clinic staff do not store food and drinks in refrigerators or freezers or on countertops or other areas where there is blood or other potentially infectious materials. Managers ensured that sterile commercial supplies are not expired. Managers minimize the risk of infection when storing and disposing of medical (infectious) waste.



NM Areas Reviewed (continued) Findings Recommendations NA Managers ensured unobstructed access to

fire alarms/pull stations. Access to fire extinguishers is unobstructed.

NA For fire extinguishers located in large rooms or are obscured from view, managers identified the locations of the fire extinguishers with signs. Exit signs are visible from any direction. Exit routes from the building are unobstructed. Staff wear VA-issued identification badges. Managers control access to and from areas identified as security sensitive. Managers installed an alarm system or panic buttons in high-risk areas. Managers reviewed the CBOC’s inventory of hazardous materials for accuracy twice within the prior 12 months. Managers had the CBOC’s safety data sheets for chemicals readily available for the staff. Managers provided visual and auditory privacy for veterans at check-in. Managers provided visual and auditory privacy for patients in the interview areas. Managers equipped examination room doors with either an electronic or manual lock. Managers ensured the availability and use of a privacy sign to indicate that a telehealth visit is in progress. Documents containing patient-identifiable information are not visible or unsecured.



NM Areas Reviewed (continued) Findings Recommendations All computer screens are locked when not in use. Information is not viewable on monitors in public areas. Window coverings, if present, provide privacy. Patient-identifiable information is protected on laboratory specimens during transport so that patient privacy is maintained. The examination room(s) for women veterans are located in a space where they do not open into a public waiting room or a high-traffic public corridor. Adequate privacy for women veterans is provided in the examination rooms. Feminine hygiene products are available in examination rooms where pelvic examinations are performed or in bathrooms within close proximity. Women’s public restrooms have feminine hygiene products and disposal bins available for use. Multi-dose medication vials are not expired. All medications are secured from unauthorized access. The information technology network room/server closet is secured/locked. Access to the information technology network room/server closet is restricted to personnel authorized by Office of Information and Technology, as evidenced by a list of authorized individuals. Access to the information technology network room/server closet is documented, as evidenced by the presence of a sign-in/sign-out log.



HT Enrollment

The purpose of this review was to determine whether the facility’s CBOCs and OOCs are compliant with selected VHA documentation requirements for the enrollment, assessment, and monitoring of HT patients.b

We reviewed relevant documents and 46 EHRs. We also validated findings with key managers and staff. The table below shows the areas reviewed for this topic. The facility generally met requirements. We made no recommendations.

Table 3. HT Enrollment

NM Areas Reviewed Findings Recommendations Clinicians entered a consult for HT services. Clinicians completed the HT enrollment requests or “consults.” Clinicians documented contact with the patient to evaluate suitability for HT services. Clinicians documented the patient or caregiver’s verbal informed consent for HT services. Clinicians documented assessments and treatment plans for HT patients. Providers signed HT assessments and treatment plans. Monthly monitoring notes were documented for each month of HT program participation. Documentation of HT enrollment (consult, screening, and/or initial assessment notes) was completed prior to the entry of monthly monitoring notes.



Outpatient Lab Results Management

The purpose of this review was to determine whether CBOCs/OOCs are compliant with VHA requirements for the patient notification and follow up of selected outpatient lab results.c

We reviewed relevant documents and 45 EHRs. We also validated findings with key managers and staff. The table below shows the areas reviewed for this topic. The area marked as NM did not meet applicable requirements and needed improvement.

Table 4. Outpatient Lab Results Management

NM Areas Reviewed Findings Recommendations The facility has a written policy regarding communication of lab results from diagnostic practitioner to ordering practitioner. The facility has a written policy for the communication of lab results that included all required elements.

X Clinicians notified patients of their lab results.

Clinicians did not consistently notify 10 of 45 patients (22 percent) of their lab results within 14 days as required by VHA.

We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.

Clinicians documented in the EHR all attempts to communicate with the patients regarding their lab results. Clinicians provided interventions for clinically significant abnormal lab results.



PTSD Care

The purpose of this review was to assess whether CBOCs/OOCs are compliant with selected VHA requirements for PTSD follow up in the outpatient setting.d

We reviewed relevant documents and 50 EHRs. We also validated findings with key managers and staff. The table below shows the areas reviewed for this topic. The facility generally met requirements. We made no recommendations.

Table 5. PTSD Care

NM Areas Reviewed Findings Recommendations Each patient with a positive PTSD screen received a suicide risk assessment. Suicide risk assessments for patients with positive PTSD screens are completed by acceptable providers. Acceptable providers established plans of care and disposition for patients with positive PTSD screens. Acceptable providers offered further diagnostic evaluations to patients with positive PTSD screens. Providers completed diagnostic evaluations for patients with positive PTSD screens. Patients, when applicable, received mental health treatment.


Review of CBOCs and OOCs of Central California VA Health Care System, Fresno, CA Appendix A

Clinic Profiles The CBOC/OOC review evaluates the quality of care provided to veterans at all of the outpatient clinics under the parent facility’s oversight.2 In addition to PC integrated with women’s health, mental health, and tele-health services, the CBOCs provide various specialty care and ancillary services. The following table provides information relative to each of the outpatient clinics and lists the additional specialty care and ancillary services provided at each location.

Outpatient Workload / Encounters3 Services Provided4

Location Station

# Rurality5 Outpatient

Classification6 PC MH Specialty Clinics7

Specialty Care8 Ancillary Services9

Merced, CA 570GA Urban Primary Care CBOC

6,595 2,450 248 Optometry Audiology Diabetic Retinal Screening

Tulare, CA 570GB Urban Primary Care CBOC

9,504 2,433 314 Dermatology Audiology Diabetic Retinal Screening

HBPC MOVE! Program10

Nutrition Oakhurst, CA 570GC Rural Primary Care

CBOC 4,222 1,222 126 NA Audiology

2 Includes all CBOCs in operation before August 15, 2015. 3 An encounter is a professional contact between a patient and a practitioner vested with responsibility for diagnosing, evaluating, and treating the patient’s condition. Encounters occur in both the outpatient and inpatient setting. 4 The denoted Specialty Care and Ancillary Services are limited to Primary Clinic Stops with a count ≥ 100 encounters during the October 1, 2014, through September 30, 2015, timeframe at the specified CBOC. 5 http://vssc.med.va.gov/ 6 VHA Handbook 1006.02, VHA Site Classifications and Definitions, December 30, 2013. 7 The total number of encounters for the services provided in the “Specialty Care” column. 8 Specialty Care Services refer to non-Primary Care and non-Mental Health services provided by a physician. 9 Ancillary Services refer to non-Primary Care and non-Mental Health services that are not provided by a physician. 10 VHA Handbook 1120.01, MOVE! Weight Management Program for Veterans, March 31, 2011.


http://vssc.med.va.gov/

Review of CBOCs and OOCs of Central California VA Health Care System, Fresno, CA Appendix B

Patient Aligned Care Team Compass Metrics

Data Definition.e The average number of calendar days between a New Patient’s PC completed appointment (clinic stops 322, 323, and 350, excluding Compensation and Pension appointments) and the earliest of three possible preferred (desired) dates (Electronic Wait List (EWL), Cancelled by Clinic Appointment, Completed Appointment) from the completed appointment date. Note that prior to FY15, this metric was calculated using the earliest possible create date.



Data Definition. e The average number of calendar days between an Established Patient’s PC completed appointment (clinic stops 322, 323, and 350, excluding Compensation and Pension appointments) and the earliest of three possible preferred (desired) dates (Electronic Wait List (EWL), Cancelled by Clinic Appointment, Completed Appointment) from the completed appointment date.



Data Definition.e The total Emergency Room/Urgent Care encounters for assigned PC patients in the last 12 months divided by the Team Assignments. VHA Emergency Room/Urgent Care encounters are defined as encounters with a Primary Stop Code of 130 or 131 in either the primary or secondary position, excluding encounters with a Secondary Stop Code of 107, 115, 152, 311, 333, 334, 999, 474, 103, 430, 328, 321, 329, or 435 and the encounter was with a licensed independent practitioner (MD, DO, RNP, PA).



Data Definition.e The percent of assigned PC patients discharged from any VA facility who have been contacted by a PC team member within 2 business days during the reporting period. Patients are excluded if they are discharged from an observation specialty and/or readmitted within 2 business days to any VA facility. Team members must have been assigned to the patient’s team at the time of the patient’s discharge.


Review of CBOCs and OOCs of Central California VA Health Care System, Fresno, CA Appendix C

Veterans Integrated Service Network Director Comments

Department of MemorandumVeterans Affairs

Date: December 23, 2015

From: Director, Sierra Pacific Network (10N21)

Subject: CBOC and OOC Review of the Central California VA Health Care System, Fresno, CA

To: Director, Los Angeles Office of Healthcare Inspections (54LA)

Director, Management Review Service (VHA 10AR MRS OIG CAP CBOC)

1. Thank you for the opportunity to review the draft CBOC OIG reviewfinding. The facility has developed the action plan for the one findingthat was identified during the review.

2. Attached is the action plan. Should you have any questions pleasecontact Terry Sanders, Associate Quality Manager for VISN 21 at(707) 562-8350

Sheila M. Cullen


Review of CBOCs and OOCs of Central California VA Health Care System, Fresno, CA Appendix D

Facility Director Comments

Department of MemorandumVeterans Affairs

Date: December 17, 2015

From: Director, Central California VA Health Care System (570/00)

Subject: CBOC and OOC Review of the Central California VA Health Care System, Fresno, CA

To: Director, Sierra Pacific Network (10N21)

1. I appreciate the opportunity to provide our input to the VA-OIG Community Base Outpatient Clinic and Other Outpatient Clinics (CBOC and OOC) review of our health care system which took place during the week of November 30, 2015.

2. I concur with all the findings and suggested improvement actions.

3. On behalf of our health care system, I would like to express my thanks to the OIG-CBOC and OOC review team which visited our facility. We found the team members not only fair in their assessment, but very helpful throughout our preparatory activities and during the review itself.

4. We appreciate the important feedback we received from this review and will use the information to further strengthen our administrative and clinical operations.



Comments to OIG’s Report

The following Director’s comments are submitted in response to the recommendation in the OIG report:

OIG Recommendation

Recommendation 1. We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.

Concur

Target date for completion: April 1, 2016

Facility response:

The health care system will implement an action plan to ensure that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA. Completion of this notification process, as implemented by Patient Aligned Care Team (PACT) members, will be appropriately documented in each patient’s medical record.

Patient Aligned Care Team (PACT) members have received education which emphasizes the importance of communicating normal lab results and documenting this communication. PACT members have been assigned to monitor and track completed lab results and associated documentation for compliance with VHA requirements.

An audit regarding the communication of normal laboratory results will be completed for at least sixty (60) patients each month for labs ordered in the outpatient clinics. This audit will continue for three (3) consecutive months, beginning in January 2016 and ending in March 2016. Team members displaying inconsistent performance regarding the notification process will be re-educated as appropriate.

Sustained compliance will be defined through incremental monthly improvements compared to the baseline compliance rate of 78%. By March 2016, 90% of the charts audited will meet performance expectations.


Review of CBOCs and OOCs of Central California VA Health Care System, Fresno, CA Appendix E

Office of Inspector General Contact and Staff Acknowledgments

Contact For more information about this report, please contact the OIG at (202) 461-4720.

Inspection Team Jovie Yabes, RN, Team Leader Daisy Arugay, MT Stacy DePriest, LCSW Kathleen Shimoda, RN Carol Torczon, RN

Other Contributors

Shirley Carlile, BA Lin Clegg, PhD Marnette Dhooghe, MS Jackelinne Melendez, MPA Jennifer Reed, RN, MSHI Larry Ross, Jr., MS Marilyn Stones, BS Mary Toy, RN, MSN Jarvis Yu, MS


Review of CBOCs and OOCs of Central California VA Health Care System, Fresno, CA Appendix F

Report Distribution

VA Distribution

Office of the Secretary Veterans Health Administration Assistant Secretaries General Counsel Director, Sierra Pacific Network (10N21) Director, Central California VA Health Care System (570/00)

Non-VA Distribution

House Committee on Veterans’ Affairs House Appropriations Subcommittee on Military Construction, Veterans Affairs, and

Related Agencies House Committee on Oversight and Government Reform Senate Committee on Veterans’ Affairs Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and

Related Agencies Senate Committee on Homeland Security and Governmental Affairs National Veterans Service Organizations Government Accountability Office Office of Management and Budget U.S. Senate: Barbara Boxer, Dianne Feinstein U.S. House of Representatives: Jim Costa, Sam Farr, Tom McClintock, Kevin

McCarthy, Devin Nunes, David Valadao

This report is available at www.va.gov/oig.


http://www.va.gov/oig

Review of CBOCs and OOCs of Central California VA Health Care System, Fresno, CA Appendix G

Endnotes

a References used for the EOC review included: International Association of Healthcare Central Services Materiel Management, Central Service Technical

Manual, 7th ed. Joint Commission, Joint Commission Comprehensive Accreditation and Certification Manual, July 1, 2015. National Fire Protection Association (NFPA), NFPA 10: Installation of Portable Fire Extinguishers, 2013. National Fire Protection Association (NFPA), NFPA 101: Life Safety Code, 2015. US Department of Health and Human Services, Health Information Privacy: The Health Insurance Portability

and Accountability Act (HIPAA) Enforcement Rule, February 16, 2006. US Department of Labor, Occupational Safety and Health Administration (OSHA), Fact Sheet: Hazard

Communication Standard Final Rule, n.d. US Department of Labor, Occupational Safety and Health Administration (OSHA), Regulations (Standards –

29 CFR), 1910 General Industry Standards, 120 Hazardous Waste Operations and Emergency Response, February 8, 2013.

US Department of Labor, Occupational Safety and Health Administration (OSHA), Regulations (Standards – 29 CFR), 1910 General Industry Standards, 1030 Bloodborne Pathogens, April 3, 2012.

VA Directive 0059, VA Chemicals Management and Pollution Prevention, May 25, 2012. VA Handbook 6500, Risk Management Framework for VA Information Systems – Tier 3: VA Information

Security Program, March 10, 2015. VHA Center for Engineering, Occupational Safety, and Health (CEOSH), Emergency Management Program

Guidebook, March 2011. VHA Directive 2011-007, Required Hand Hygiene Practices, February 16, 2011. VHA Directive 2012-026, Sexual Assaults & Other Defined Public Safety Incidents in VHA Facilities,

September 27, 2012. VHA Handbook 1006.1, Planning and Activating Community-Based Outpatient Clinics, May 19, 2004. VHA Handbook 1101.10, Patient Aligned Care Team (PACT) Handbook, February 5, 2014. VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics, September 11,

2008. VHA Handbook 1330.01, Health Care Services for Women Veterans, May 21, 2010. VHA Handbook 1605.1, Privacy and Release of Information, May 17, 2006. VHA Handbook 1907.01, Health Information Management, July 22, 2014. VHA Telehealth Services, Clinic Based Telehealth Operations Manual, July 2014. b References used for the HT Enrollment review included: VHA Office of VHA Telehealth Services Home Telehealth Operations Manual, April 13, 2015.

Accessed from: http://vaww.telehealth.va.gov/pgm/ht/index.asp. c References used for the Outpatient Lab Results Management review included: VHA, Communication of Test Results Toolkit, April 2012. VHA Handbook 2009-019, Ordering and Reporting Test Results, March 24, 2009. d References used for the PTSD Care review included: Department of Veterans Affairs Memorandum, Information Bulletin: Clarification of Posttraumatic Stress

Disorder Screening Requirements, August 2015. VA/DoD Clinical Practice Guideline for Management of Post-Traumatic Stress, Version 2.0, October 2010. VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics, September 11,

2008. VHA Handbook 1160.03, Programs for Veterans with Post-Traumatic Stress Disorder (PTSD), March 12, 2010. VHA Technical Manual – PTSD, VA Measurement Manual PTSD-51. e Reference used for Patient Aligned Care Team Compass data graphs: Department of Veterans’ Affairs, Patient Aligned Care Teams Compass Data Definitions, accessed: June 25,

2015.


http://vaww.telehealth.va.gov/pgm/ht/index.asp